Healthcare Provider Details

I. General information

NPI: 1699889337
Provider Name (Legal Business Name): BRUCE LEE BERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

IV. Provider business mailing address

2791 RICHMOND AVE SUITE 201
STATEN ISLAND NY
10314-5859
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax: 718-816-3749
Mailing address:
  • Phone: 718-816-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number185296-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: